THE  MENTAL  HEALTH  OF  THE  COIiL,.uNITY 

AND  THE  WORK  OF  THE  PSYCHIATRIC 

DISPENSARY 


By 
C.  MACFIE  CAMPBELL,  M.  D. 

Johns  Hopkins  Hospital 


THE  NATIONAL  COMMITTEE  FOR 

MENTAL  HYGIENE,  Inc. 

50  Union  Square 

New  York  City 


REPRINT  No.  21 


w 

Wyt  Rational  Committee  for  JHental 


FOUNDED  1909  INCOBPOBATED  1916 

50  UNION  SQUARE,  NEW  YORK  CITY 

President 
DB.  LEWELLYS  F.  BARKER 


CHARLES  W.  ELIOT 


Vice^Presidenta 

Treasurer 
OTTO  T.  BANKAHD 


DR.  WILLIAM  H.  WELCH 


Executive  Committee 
DB.  WILLIAM  L.  RUSSELL,  Chairman 
DR.  LEWELLTS  F.  BARKER  DB.  WALTER  E.  FEBNALD 

Da.  GEORGE  BLUMER  MATTHEW  C.  FLEMING 

STEPHEN  P.  DUGGAN  DR.  GEORGE  H.  KIBBT 


Committee  on  Mental  Deficiency 
DR.  WALTER  E.  FERNALD,  Chairman 
DR.  L.  PIERCE  CLARK 

DR.  CHARLES  S.  LITTLE 

Finance  Committee 

RUSSELL  H.  CHITTENDEN,  Chairman 
OTTO  T.  BANNARD 

DR.  WILLIAM  B.  COLET 

WILLIAM  J.  HOGGSON 


War  Work  Committee 
MAJOR  PEARCE  BAILET,  Chairman 

DR.  FRANKWOOD  E.  WILLIAMS,  Vice-Chairman 

Executive  Officers 

DR.  THOMAS  W.  SALMON,  Medical  Director 
DR.  FRANKWOOD  E.  WILLIAMS,  Associate 
Medical  Director 

CLIFFORD  W.  BEEBS,  Secretary 


MEMBERS 


MBS.  MILO  M.  ACKER,  Hornell,  N.  Y. 

JANE  ADDAUS,  Chicago 

EDWIN  A.  ALDEBMAN,  Charlottesville,  Va. 

MBS.  A.  A.  ANDEBSON,  Greenwich,  Conn. 

DR.  PEABCE  BAILEY,  New  York 

DB.  CHARLES  P.  BANCROFT,  Concord,  N.  H. 

OTTO  T.  BANNABD,  New  York 

DB.  LEWELLYS  F.  BARKER,  Baltimore 

DR.  ALBERT  M.  BABBETT,  Ann  Arbor,  Mich. 

DB.  FBANK  BILLINGS,  Chicago 

SUBG.  GEN.  RUPEBT  BLUE,  Washington 

DR.  GEORGE  BLUMEB,  New  Haven 

DR.  G.  ALDER  BLUMER,  Providence 

WILLIAM  H.  BURNHAM,  Worcester 

DR.  C.  MACFIE  CAMPBELL,  Baltimore 

RUSSELL  H.  CHITTENDEN,  New  Haven 

DR.  L.  PIERCE  CLARK,  New  York 

DR.  WILLIAM  B.  COLBY,  New  York 

DB.  OWEN  COPP,  Philadelphia 

DR.  CHARLES  L.  DANA,  New  York 

C.  B.  DAVENPOBT,  Cold  Spring  Harbor,  N.  Y. 

STEPHEN  P.  DUGGAN,  New  York 

CHARLES  W.  ELIOT,  Cambridge 

DB.  CHABLES  P.  EMERSON,  Indianapolis 

ELIZABETH  E.  FABRELL,  New  York 

W.  H.  P.  FAUNCE,  Providence 

KATHEBINE  S.  FELTON,  San  Francisco 

DR.  WALTER  E.  FERNALD,  Waverley,  Mass. 

JOHN  H.  FINLEY,  Albany 

IRVING  FISHER,  New  Haven 

MATTHEW  C.  FLEMING,  New  York 

HORACE  FLETCHER,  New  York 

HOMER  FOLKS,  New  York 

DR.  CHARLES  H.  FRAZIER,  Philadelphia 

JAMES,  CARDINAL  GIBBONS,  Baltimore 

ABTHUB  T.  HADLEY,  New  Haven 

DR.  WILLIAM  HEALY,  Boston 

DR.  ARTHUR  P.  HERRING,  Baltimore 

HENRY  L.  HIGGINSON,  Boston 

DR.  AUGUST  HOCH,  Santa  Barbara,  Cal. 

WILLIAM  J.  HOGGSON,  Greenwich,  Conn. 

DR.  WALTER  B.  JAMES,  New  York 

MBS.  WILLIAM  JAMES,  Cambridge 

DAVID  STARR  JORDAN,  Palo  Alto,  Cal. 

HARRY  PRATT  JUDSON,  Chicago 


DR.  CHARLES  G.  KEBLEY,  New  York 

DR.  GEORGE  H.  KIRBY,  New  York 

FRANKLIN  B.  KIRKBRIDE,  New  York 

DR.  GEORGE  M.  KLINE,  Boston 

JOHN  KOBEN,  Boston 

JULIA  C.  LATHBOP,  Washington 

ADOLPH  LEWISOHN,  New  York 

SAMUEL  McCuNE  LINDSAY,  New  York 

DB.  CHABLES  S.  LITTLE,  Thiells,  N.  Y. 

GEOBGE  P.  McLEAN,  Simsbury,  Conn. 

V.  EVERIT  MACY,  Scarborough,  N.  Y. 

MARCUS  M.  MARKS,  New  York 

LEE  MEBrwETHER,  St.  Louis 

MRS.  WILLIAM  S.  MONROE,  Chicago 

DR.  J.  MONTGOMERY  MOSHER,  Albany 

DR.  FRANK  P.  NORBURY,  Jacksonville,  111. 

CYRUS  NORTHROP,  Minneapolis 

WILLIAM  CHUBCH  OSBORN,  New  York 

DB.  STEWART  PATON,  Princeton 

DB.  FBEDEBICK  PETERSON,  New  York 

HENBY  PHIPPS,  New  York 

GIFFORD  PINCHOT,  Washington 

FLOBENCE  M.  RHETT,  New  York 

DB.  ROBERT  L.  RICHARDS,  Talmage,  Cal. 

MRS.  CHAS.  C.  RUMSEY,  Wheatley  Hills,  N.  Y. 

DR.  WILLIAM  L.  RUSSELL,  White  Plains,  N.  Y. 

JACOB  GOULD  SCHURMAN,  Ithaca 

DR.  ELMER  E.  SOUTHARD,  Boston 

DB.  M.  ALLEN  STARR,  New  York 

DR.  HENRY  R.  STEDMAN,  Brookline,  Mass. 

ANSON  PHELPS  STOKES,  New  Haven 

DR.  CHARLES  F.  STOKES,  Briarcliff,  N.  Y. 

SHERMAN  D.  THACHER,  Nordhoff,  Cal. 

VICTOR  MOBBIS  TYLER,  New  Haven 

MRS.  WILLIAM  K.  VANDEBBILT,  New  York 

HENRY  VAN  DYKE,  Princeton 

DR.  HENRY  P.  WALCOTT,  Cambridge 

LILLIAN  D.  WALD,    New  York 

DR.  WILLIAM  H.  WELCH,  Baltimore 

BENJAMIN  IDE  WHEELER,  Berkeley,  Cal. 

DR.  WILLIAM  A.  WHITE,  Washington 

DR.  HENRY  SMITH  WILLIAMS,  New  York 

ROBEBT  A.  WOODS,  Boston 

ROBEBT  M.  YERKES,  Minneapolis 


CHIEF  PURPOSES:  To  work  for  the  conservation  of  mental  health;  to  promote  the  study  of  mental  disorders  and  mental g 
defects  in  all  their  forms  and  relations;  to  obtain  and  disseminate  reliable  data  concerning  them;  to  help  raise  the  st 
of  care  and  treatment;  to  help  co-ordinate  existing  agencies.  Federal,  State  and  local,  and  to  organize  in  euery  State 
affiliated  Society  for  Mental  Hygiene. 


,,^   ..,,.,„ 

- 
[Reprinted  from  MENTAL  HYGIENE,  Vol.  I,  No.  4,  October,  1917] 


THE  MENTAL  HEALTH  OF  THE  COMMUNITY 

AND  THE  WORK  OF  THE  PSYCHIATRIC 

DISPENSARY* 

C.   MACFIE   CAMPBELL,   M.D. 

Johns  Hopkins  Hospital 

THE  unfortunate  patient,  who  suffers  from  one  of  the  countless 
ills  to  which  human  flesh  is  heir,  as  a  rule  has  insight  into 
his  condition  and  knows  in  a  general  way  where  to  get  help;  even 
though  unable  to  pay  special  fees  he  can  go  to  a  special  clinic  such 
as  the  eye  clinic,  or  can  consult  the  dispensary  of  the  general 
hospital,  where  he  is  referred  to  the  suitable  special  department. 
The  nature  of  the  work  of  each  special  department  is  familiar  in 
its  general  outline  to  the  man  in  the  street. 

The  situation  is  somewhat  different  with  regard  to  the  depart- 
ment that  deals  with  mental  disorders;  the  public  and  even  the 
medical  profession  are  here  not  so  well  informed.  The  patient 
suffering  from  a  mental  disorder  may  have  no  inkling  of  his 
sickness;  the  family  and  social  agencies  frequently  fail  to  realize 
that  the  situation  is  one  demanding  expert  medical  advice.  It  is 
important,  therefore,  to  diffuse  more  widely  the  knowledge  of 
what  help  is  offered  by  a  psychiatric  dispensary,  and  of  what 
type  of  cases  should  be  brought  there. 

To  many  the  name  "psychiatric  dispensary"  suggests  little  or 
nothing;  the  term  "mental  clinic"  or  "mental  out-patient  de- 
partment" sounds  more  familiar,  and  yet  even  so  simple  a  term 
may  call  up  in  the  minds  of  many  a  very  misleading  picture. 
Although  living  in  the  twentieth  century,  we  are  not  free  from  the 
trammels  of  medieval  thought.  We  are  apt  to  deal  with  words» 
the  symbols  of  reality,  rather  than  with  the  facts  of  experience. 
So  the  term  mental  disorder,  like  the  legal  term  insanity,  has  a 
certain  ominous  ring  about  it  which  makes  people  tend  to.  avoid  it. 

It  is  well,  therefore,  to  begin  by  freeing  our  minds  from  some 
general  misconceptions  before  passing  on  to  the  presentation  of 
concrete  facts.  Mental  disorders  are  disorders  of  human  adjust- 
ment, maladaptations,  unhygienic  compromises,  immature  or 
distorted  methods  of  meeting  the  complex  situations  of  life.  The 
mental  out-patient  clinic  or  psychiatric  dispensary  deals  with  such 

*  Read  before  the  Mental  Hygiene  section  of  the  National  Conference  of  Charities  and 
Correction,  Pittsburg,  June  12,  1917. 

1 


2  MENTAL  HYGIENE 

disorders  of  adjustment;  it  deals  with  the  failures  of  the  individual 
to  meet  life's  problems.  Unlike  internal  medicine,  psychiatry 
cannot  limit  itself  to  the  failure  of  single  organs  or  groups  of 
organs  to  deal  with  their  problems;  it  has  to  deal  with  the  malad- 
justments of  the  personality  as  a  whole.  Psychiatry  may  there- 
fore be  considered  as  personal  medicine,  as  opposed  to  impersonal 
medicine;  while  in  other  departments  the  personality  may  be 
ignored,  although  not  always  with  impunity,  in  the  mental  clinic 
the  personality  is  the  organic  unit  with  which  we  work.  It  is 
true  that  disorders  of  the  individual  organs  and  of  groups  of 
organs  may  cause  modifications  of  the  personality.  The  per- 
sonality is  not  something  outside  of  and  apart  from  the  constituent 
organs  of  the  body;  it  is  the  total  activity  of  these  organs  more 
adequately  conceived.  The  study  of  the  personality  and  its 
disorders  involves  the  study  of  all  the  bodily  organs,  but  in  a 
more  complete  setting  than  is  necessary  in  internal  medicine. 

In  the  mental  clinic,  therefore,  we  deal  with  patients  whose 
symptoms  require  for  their  understanding  a  study  of  the  per- 
sonality and  of  its  problems.  Mental  disorders  are  not  disorders 
whose  symptoms  necessarily  are  mental,  but  whose  roots  are 
mental,  that  is  whose  roots  cannot  be  understood  without  study- 
ing the  patient  in  his  complete  human  relations.  The  symptoms 
may  be  insomnia,  or  headache,  or  vomiting;  they  may  consist  of  a 
paralysis  or  a  tremor;  they  may  be  limited  to  an  apparent  blind- 
ness or  deafness  or  dumbness;  and  yet  the  disorder  may  be  a 
mental  disorder  because  its  roots  lie  in  the  difficulty  the  person- 
ality has  in  its  adjustment  to  the  situation.  The  personality, 
in  the  face  of  difficulties,  may  find  refuge  in  phantasies,  deliria 
or  hallucinations,  but  also  in  aches  and  pains  and  palsies,  and  the 
latter  may  be  as  truly  evidence  of  mental  disorder  as  the  former. 

Symptoms  such  as  paralysis  or  blindness  may  be  the  signal  of  a 
complex  human  difficulty  while  the  individual  organs  are  sound; 
on  the  other  hand  changes  of  personality,  moods,  hallucinations 
and  delusions  may  be  the  sign  of  the  disorder  of  some  individual 
organ  or  group  of  organs.  The  organs  involved  may  be  the 
central  nervous  system,  the  glands  which  are  at  the  very  basis 
of  the  emotional  life,  or  some  other  organ  such  as  the  stomach,  or 
lungs.  Where  the  personality  is  involved  in  this  secondary  way 
the  mental  symptoms  are  merely  symptomatic  of  disorders,  the 
study  and  treatment  of  which  can  be  carried  on  along  the  nar- 
rower lines  of  internal  medicine. 


MENTAL  HEALTH  OF  THE   COMMUNITY  3 

A  survey  of  the  actual  work  done  in  the  psychiatric  dispensary 
may  begin  properly  with  the  children;  these  may  be  divided  con- 
veniently into  the  subnormal  and  the  neurotic  group. 

With  regard  to  the  former  group,  the  early  recognition  and 
complete  study  of  any  constitutional  defect  is  extremely  im- 
portant; this  enables  the  physician  to  advise  the  teacher,  to  guide 
the  mother,  to  safeguard  the  child  from  deleterious  influences, 
from  drifting  into  unhealthy  or  delinquent  habits,  from  becoming 
the  tool  of  the  unscrupulous.  Pronounced  backwardness  at 
school  without  obvious  cause  is  a  sufficient  indication  that  a 
psychiatric  examination  is  required. 

The  neurotic  group  is  composed  of  those  children  who  show  such 
symptoms  as  night-terrors,  bed-wetting,  tantrums  of  temper, 
excessively  fidgety  behavior,  poor  sexual  habits,  pilfering,  ro- 
mancing, unexplained  moods,  marked  cruelty  or  other  anomalous 
traits  of  character. 

In  every  case  the  physician  aims  first  at  a  thorough  study  of  the 
child  from  the  point  of  view  of  his  physique,  his  intelligence,  his 
emotional  life  and  general  balance;  and  then  at  a  study  of  the  in- 
fluence of  the  environment  on  the  formation  of  habits  of  the 
child.  With  the  teacher  he  discusses  the  school  situation;  with 
the  parent  he  has  to  review  carefully  the  home  behavior  of  the 
child,  the  development  of  the  neurotic  traits,  and  the  conditions 
which  may  influence  them.  The  individual  child  thus  may  get 
help,  symptoms  be  relieved,  improper  habits  checked;  but  an 
important  by-product  is  that  the  teacher  gains  a  broader  con- 
ception of  the  nature  of  education,  the  parent  a  deeper  insight  into 
the  problem  of  training  the  child — a  task  often  so  honestly  taken 
up  and  so  inefficiently  carried  out. 

In  order  that  the  teacher  may  furnish  essential  data  to  the  dis- 
pensary physician,  the  latter  should  supply  simple  forms  in  which 
the  important  facts  can  be  briefly  entered;  the  teacher  may  then 
learn  to  fill  in  such  a  form,  not  as  a  burdensome  routine  duty  but 
with  the  same  interest  with  which  the  physician  makes  his  notes. 
Similar  co-operation  should  be  obtained  from  all  social  workers 
dealing  with  the  problems  of  childhood,  when  they  bring  one  of 
their  wards  to  the  dispensary  for  examination.  This  of  course 
applies  equally  where  the  ward  is  a  child,  a  wayward  adult,  or 
delinquent,  or  drug  addict.  The  social  worker  should  realize 
the  importance  of  a  psychiatric  opinion  on  such  cases,  and  should 
prepare  the  available  data  with  some  insight  into  the  require- 


4  MENTAL  HYGIENE 

ments  of  the  physician;  while  the  latter,  in  the  light  of  these  data 
and  the  examination  of  the  individual,  should  be  prepared  to  fur- 
nish the  worker  an  opinion,  which  will  make  the  actual  manage- 
ment of  the  case  more  efficient.  Such  work  will  be  a  source  of 
instruction  to  the  individual  worker;  it  will  make  less  haphazard 
and  more  firmly  based  on  rational  principles  the  work  of  many 
organizations  dealing  with  prisoners,  unmarried  mothers,  juvenile 
delinquents,  and  dependents  of  other  types.  Work  of  this  type 
will  do  much  to  instruct  the  whole  community  as  to  the  under- 
lying causes  of  these  disorders  of  conduct  and  the  necessity  of 
dealing  with  them  at  an  early  stage,  that  is,  in  the  school  period. 

The  adult  patients  of  the  dispensary  present  a  great  variety 
of  practical  problems.  Sometimes  the  problems  are  those  of  the 
general  dispensary;  that  is  especially  true  where  the  mental  symp- 
toms point  to  some  underlying  disease,  either  of  the  central  nerv- 
ous system  (e.  g.,  brain  tumor)  or  of  some  other  organ  or  group  of 
organs  (e.  g.,  exophthalmic  goitre).  But  in  a  large  group  of  cases 
the  symptoms  are  intimately  associated  with  personal  difficulties 
of  adjustment,  and  a  thorough  study  has  to  be  made  of  the  whole 
attitude  and  balance  of  the  patient,  and  of  the  life-situation  in 
which  he  finds  himself. 

A  painstaking  review  and  discussion  of  those  factors,  which 
make  for  happiness  or  unhappiness  in  life,  is  often  a  relief  and 
revelation  to  patients,  whose  ailments  have  hitherto  been  treated 
in  the  traditional  impersonal  way  by  drugs,  rest-cures,  and  opera- 
tive measures. 

Thus  a  young  man  came  prepared  to  enter  the  hospital  for  the 
treatment  of  persistent  headache;  the  headache  was  associated 
with  worry  over  faulty  sexual  habits.  A  frank  discussion  of  the 
whole  situation  relieved  his  mind  considerably;  he  was  en- 
couraged to  improve  his  adaptation  outside  rather  than  to  take 
refuge  in  the  hospital.  Accordingly,  a  somewhat  uncongenial  en- 
vironment was  given  up  for  residence  in  town,  suitable  employ- 
ment was  found,  the  patient  took  up  the  regular  gymnasium  work 
of  the  Y.  M.  C.  A.  along  with  other  recreation  in  the  evening. 
Since  then  the  patient's  attitude  toward  life  has  been  transformed 
from  one  of  sensitive  seclusiveness  to  a  much  more  healthy  out- 
look; instinctive  control  is  satisfactory;  headache  is  no  longer 
spontaneously  referred  to,  while  his  improvement  has  been  an 
enormous  relief  to  his  family.  Encouraged  by  the  improve- 
ment of  the  patient,  a  brother  has  also  sought  advice. 


MENTAL  HEALTH  OF  THE   COMMUNITY  5 

While  the  aim  of  the  treatment  is  the  readjustment  of  the 
patient  to  the  environment,  the  method  is  largely  re-educational; 
at  the  same  time,  such  general  measures  as  drugs,  diet  and  baths  are 
not  neglected.  Re-education  of  the  patient  means  that  he  studies 
his  own  personal  difficulties  in  a  rather  intensive  way  (assuming  he 
has  the  requisite  intelligence);  he  traces  out  the  factors  which 
have  influenced  his  habits  and  attitudes;  he  learns  to  face  the 
facts  of  his  life  in  their  biological  crudity  as  well  as  in  their  ethical 
and  aesthetic  setting;  he  gains  courage  to  discard  mental  make- 
shifts and  disguises. 

But  this  gain  in  honest  insight  into  the  problems  of  life  must  not 
be  a  barren  intellectual  exercise;  it  must  go  hand  in  hand  with 
a  search  for  those  practical  aids  to  the  formation  of  better  habits 
which  the  community  may  offer,  and  must  be  accompanied  by  the 
actual  utilization  of  these  aids.  In  the  daily  and  weekly  program 
the  varied  needs  of  human  nature  must  get  sufficient  recognition; 
work  should  yield  its  own  return,  opportunities  for  recreation 
should  be  available,  the  social,  intellectual,  aesthetic  and  religious 
aspects  of  life  must  not  be  ignored;  balancing  factors  in  the  way 
of  hobbies  are  to  be  encouraged,  and  the  fundamental  relations  of 
the  patient  to  his  own  family  are  of  cardinal  importance.  While 
the  physician  with  his  special  knowledge  helps  the  patient  to 
unravel  his  tangles,  the  trained  social  service  worker  plays  an 
essential  role  in  directing  the  first  steps  of  the  patient.  It  is  the 
aim  of  this  communication  to  outline  this  work  and  illustrate  it. 

A  girl  of  twenty-one  with  a  slight  physical  deformity  took  it 
very  seriously  to  heart,  saw  her  life  as  without  any  promise,  and 
harped  on  a  number  of  physical  complaints  which  seemed  to  have 
no  adequate  cause.  A  review  of  her  case  showed  that,  partly 
owing  to  personal  difficulties,  partly  owing  to  faulty  training  and 
difficult  circumstances,  she  had  developed  her  invalidism  as  a  pro- 
tection, while  her  true  interests  found  no  outlet.  Frequent  inter- 
views with  the  physician  enabled  her  to  adopt  the  latter's  attitude 
toward  her  symptoms.  At  the  same  time  the  social  service 
worker*  got  in  touch  with  the  patient's  sister,  and  did  much  to 
correct  the  attitude  of  the  latter,  who  had  fostered  the  patient's 
invalidism.  She  put  the  patient  in  the  way  of  developing  her 
artistic  talents  by  arranging  for  an  exceptional  educational  op- 

*  I  take  this  opportunity  to  express  my  indebtedness  to  Miss  S.  L.  Lyons,  in  charge  of 
the  Social  Service  Department  of  the  Psychiatric  Dispensary,  for  her  assistance  in  the 
preparation  of  this  paper. 


6  MENTAL  HYGIENE 

portunity.  The  patient  was  soon  able  to  discard  her  protective 
invalidism;  she  has  made  a  good  start  on  the  road  to  economic  in- 
dependence; her  attitude  toward  life  is  one  of  cheerfulness  and 
hope  instead  of  discouragement  and  resignation,  while  the  slight 
physical  deformity  has  shrunk  in  her  perspective  from  a  mountain 
to  a  molehill,  and  as  a  matter  of  fact  is  not  noticed  by  her  com- 
rades. The  fact  that  the  patient  was  referred  to  the  dispensary 
by  the  physician  who  was  consulted  for  the  physical  deformity, 
illustrates  the  benefit  of  the  medical  profession  in  general  being 
trained  to  recognize  such  disorders,  which  are  so  apt  to  masquer- 
ade in  disguise. 

The  general  social  worker,  too,  does  well  to  respond  with  some 
sensitiveness  to  anomalies  of  personality,  and  to  know  when  to 
invite  a  psychiatric  opinion  before  planning  the  life  of  the  indi- 
vidual. A  young  woman  of  eighteen,  with  some  artistic  talent 
and  superficially  bright,  enlisted  the  sympathy  of  a  district  social 
service  worker  through  her  story  of  ill-treatment  at  home.  The 
latter  obtained  for  the  girl  the  opportunity  of  going  to  town  to 
take  up  the  study  of  art.  The  girl  soon  attracted  the  attention 
of  her  companions  by  her  phantastic  stories  and  lack  of  respon- 
sibility and  she  was  brought  to  the  psychiatric  dispensary  for 
examination.  A  thorough  review  of  her  condition  and  of  her 
early  development  showed  that  she  was  constitutionally  in- 
ferior, not  in  the  sense  of  being  intellectually  defective,  but  in  her 
response  to  ethical  standards.  This  condition  of  constitutional 
psychopathic  inferiority,  which  gives  rise  to  so  many  legal  and 
other  difficulties,  made  it  necessary  in  view  of  her  actual  behavior 
to  have  her  placed  in  a  state  hospital.  The  well-meant  endeavor 
of  the  social  worker  to  help  the  patient  went  astray,  because  the 
former  was  guided  rather  by  sentimental  considerations  than  by 
trained  insight  into  the  personality  of  the  patient.  The  contact 
of  the  general  social  worker  with  the  psychiatric  dispensary 
should  broaden  the  basis  of  much  social  work  and  be  one  more 
step  in  diffusing  knowledge  of  mental  hygiene  throughout  the 
community. 

The  consistent  and  conscientious  treatment  of  the  patient 
means  that  whatever  necessary  conditions  are  indicated  for  the 
readjustment  of  the  patient  should,  if  possible,  be  placed  at  the 
patient's  disposal,  although  the  search  for  them  takes  one  from 
the  hospital  into  the  school,  the  labor  market,  and  the  church. 
The  concrete  needs  of  the  individual  patient  have  to  be  defined 


MENTAL  HEALTH  OP  THE  COMMUNITY  7 

and  .supplied;  by  that  we  do  not  mean  that  the  situation  is  made 
too  easy  for  the  patient,  nor  that  the  patient  is  encouraged  to 
become  dependent  on  the  support  of  the  clinic.  But  the  patient 
must  be  given  more  than  general  directions,  must  at  first  be 
led,  perhaps,  until  the  way  is  more  familiar. 

To  make  the  steps  and  nature  of  the  treatment  clear,  further 
individual  cases  may  be  quoted.  A  woman  of  twenty-six  for 
several  years  had  complained  of  severe  headache,  dizziness,  vomit- 
ing, burning  pains,  insomnia  and  nervous  feelings;  the  physician 
who  had  treated  her  by  the  usual  medical  measures  for  a  long 
period  without  result,  recognized  the  true  nature  of  the  case  and 
transferred  her  to  the  psychiatric  dispensary.  The  mental  roots 
of  the  disorder  were  not  difficult  to  discover,  and  the  mental 
hygiene  of  the  patient  was  placed  on  a  better  basis.  She  was 
sensitive  about  her  ignorance  of  English;  she  got  little  satisfaction 
from  her  few  household  duties;  she  squandered  much  time  and 
energy  in  day-dreaming. 

Under  the  stimulus  of  the  social  worker,  she  was  encouraged 
to  take  systematic  lessons  in  English;  she  became  a  member  of  a 
gymnasium  class  at  the  Public  Athletic  League;  she  joined  the 
swimming  class;  she  learned  to  develop  her  home  responsibilities, 
attended  the  weekly  occupation  class  at  the  psychiatric  dispen- 
sary, and  did  some  volunteer  social  service  work.  When  the 
patient  first  came  under  observation  her  condition  was  such  that 
admission  to  a  state  hospital  was  seriously  considered  and  would 
have  been  welcomed  by  the  husband.  With  the  help  of  the 
measures  outlined  above  the  patient  improved  greatly,  although 
leaning  frequently  on  the  social  service  worker.  The  husband 
was  much  encouraged  by  the  improvement;  his  hearty  co-opera- 
tion in  the  treatment  was  the  result  of  the  support  by  the  clinic, 
and  replaced  his  previous  resignation  to  the  prospect  of  having 
her  leave  home  for  a  long  residence  in  a  hospital. 

It  is  often  so;  with  the  dispensary  to  fall  back  on  in  time  of  need, 
the  husband  or  wife,  parent  or  child,  is  often  much  more  willing 
to  undertake  the  task  of  looking  after  the  patient  at  home. 

The  treatment  of  the  patient  is  the  treatment  of  the  whole 
situation  and  the  other  members  of  the  family  must  often  receive 
psychiatric  attention,  as  in  the  following  case. 

A  man  of  forty-seven,  with  epileptiform  convulsions,  was  sus- 
pected of  malingering  by  the  social  organization  which  helped  to 
support  his  family.  Examination  at  the  psychiatric  dispensary 


8  MENTAL  HYGIENE 

determined  the  organic  nature  of  the  disorder;  he  was  operated  on 
in  the  hospital,  unfortunately  without  relief;  after  leaving  the 
hospital  he  continued  to  visit  the  psychiatric  dispensary  where  he 
attended  the  weekly  occupation  class,  his  sole  recreation.  His 
wife  preferred  to  care  for  him  at  home  than  to  have  him  admitted 
to  a  state  hospital.  It  was  found  that  two  of  his  children  showed 
neurotic  symptoms ;  they  were  accordingly  examined,  their  mother 
was  advised  as  to  the  necessary  home  hygiene,  their  school 
teachers  were  interviewed  and  informed  of  the  medical  opinion, 
gymnasium  privileges  were  arranged  for  and  the  necessary  shoes 
provided. 

The  range  of  the  work  done  by  the  dispensary  in  treating  ade- 
quately the  situation  presented  by  a  patient  is  shown  in  the  fol- 
lowing case.  A  foreigner,  cultured  but  eccentric,  was  referred  to 
the  dispensary  from  the  tuberculosis  clinic  on  account  of  his 
depressed  condition;  his  funds  were  low,  there  had  been  friction 
with  the  church  authorities,  the  fault  not  being  altogether  on  his 
side.  In  view  of  his  prejudices  and  somewhat  difficult  personality, 
the  problem  of  readjustment  was  rather  complicated.  The 
friction  with  the  church  authorities  was  smoothed  over,  a  suitable 
position  was  obtained  for  the  patient,  debts  were  paid  in  order  to 
let  him  move  from  a  quite  uncongenial  environment  to  one  more 
suitable  for  him  and  for  his  children,  clothing  was  provided  for  the 
family,  artificial  teeth  for  the  wife,  some  literature  was  put  at  the 
patient's  disposal,  and  the  basis  for  some  congenial  friendships  was 
laid.  Such  a  series  of  steps  may  seem  to  stretch  rather  far  the 
function  of  the  dispensary,  but  so  long  as  the  therapeutic  problem  is 
taken  seriously  they  are  as  essential  as  the  individual  steps  in 
surgical  or  ordinary  medical  treatment. 

From  the  economic  standpoint  the  outlay  in  such  a  case  comes 
up  for  scrutiny.  The  serious  probability  was  that  this  eccentric 
man,  with  his  cultural  interests  starved  in  a  drab  environment, 
unable  to  earn  his  living  owing  to  the  church  friction,  would  show 
progressive  embitterment  and  develop  definite  delusions.  The 
result  would  then  have  been  his  admission  to  a  state  hospital, 
perhaps  to  remain  for  life,  while  his  children  became  a  charge  on 
the  community.  By  the  measures  taken,  which  involved  an 
expenditure  of  less  than  two  hundred  dollars,  he  promises  to  be- 
come a  productive  economic  unit,  the  support  of  the  family,  get- 
ting satisfaction  out  of  life,  an  asset  to  the  culture  of  the  com- 
munity. Not  only  is  he  himself  happy,  but  the  prospects  for  the 


MENTAL  HEALTH  OF  THE   COMMUNITY  9 

healthy  development  of  his  children  are  infinitely  better.     This  is 
preventive  medicine. 

Even  in  cases  where  the  seriousness  of  the  disorder  allows  only 
palliative  treatment,  the  dispensary  can  do  much  to  outline  meas- 
ures to  reduce  friction  with  the  patient;  the  physician,  by  giving 
the  family  an  insight  into  the  medical  view  of  the  disorder,  may 
rob  it  of  much  of  its  bitterness. 

One  important  practical  decision  has  frequently  to  be  made, 
namely,  whether  the  patient  should  be  placed  in  a  hospital  even 
without  his  co-operation.  The  relatives  are  apt  to  take  the  symp- 
toms merely  at  their  face  value;  the  physician,  however,  realizes 
that  a  patient  with  incipient  paresis  may  seriously  compromise 
his  name  and  fortune,  that  a  patient  with  a  mild  depression  may 
commit  suicide,  that  a  seclusive  and  embittered  patient  may 
suddenly  commit  a  homicide.  Impressed  with  these  dangers  he 
may  urge  the  friends  of  the  patient  to  take  the  necessary  steps 
to  have  the  latter  admitted  to  a  state  hospital  or  private  sana- 
torium. In  the  popular  mind  old  associations  still  cling  to  the 
hospital  for  mental  disorders;  the  man  in  the  street  hardly  realizes 
that  they  are  hospitals  in  the  true  sense  of  the  word,  specially 
staffed  and  equipped  for  the  curative  and  palliative  treatment  of 
disease. 

One  need  not  blame  the  man  in  the  street,  for  physicians  and 
social  workers  often  require  enlightenment  on  this  topic.  In 
illustration,  I  may  quote  an  extract  from  the  letter  of  a  social 
worker,  protesting  against  the  advice  to  send  a  young  woman  to 
a  state  hospital: 

"From  a  physician's  point  of  view,  would  you  advise  further 
hospital  treatment  outside  of  an  insane  asylum?  So  long  as  she 
is  perfectly  harmless,  would  she  stand  a  better  chance  in  a  medical 
hospital  for  a  little  while  longer,  if  we  could  so  place  her?"  This 
reference  to  a  state  hospital  as  an  insane  asylum,  a  place  which  is 
not  regarded  as  a  medical  hospital  but  where  patients  should  be 
sent  only  when  they  cease  to  be  harmless  and  can  not  be  benefited 
by  further  treatment,  illustrates  a  medieval  trend  from  which 
contemporary  thought  must  be  purged.  Where  the  medieval 
attitude  still  dominates  the  institutions  of  the  state,  it  is  an  im- 
perative duty  of  the  community  to  see  that  the  hospitals  are 
brought  up  to  a  modern  level. 

It  is  not  sufficient  to  give  to  the  family  the  summary  advice  that 
commitment  to  a  state  hospital  is  necessary;  the  nature  of  the 


10  MENTAL  HYGIENE 

advice  must  be  made  clear,  any  prejudices  removed  so  far  as  pos- 
sible, the  actual  steps  for  the  admission  of  the  patient  arranged 
with  the  utmost  consideration  for  the  attitude  of  the  patient. 
The  relation  between  the  patient  and  the  physician  in  the  state 
hospital  may  be  seriously  compromised  by  injudicious  manage- 
ment of  the  patient  before  admission;  there  should  be  no  deceit; 
non-medical  interference,  such  as  the  co-operation  of  the  police, 
should  be  avoided  except  in  a  serious  emergency,  and  then  a  plain- 
clothes  man  should  be  employed. 

A  frank  attitude  towards  the  patient  may  gain  co-operation, 
even  where  the  outlook  is  not  promising.  Thus  a  woman  of 
forty -two  at  first  rejected  indignantly  the  advice  to  go  to  a  state 
hospital;  she  had  ideas  of  persecution,  thought  that  she  was  fol- 
lowed by  detectives,  threatened  to  shoot  her  persecutor,  and  was 
incensed  at  the  physician's  guarded  suggestion  that  her  whole 
attitude  required  a  detailed  examination  such  as  could  only  be 
adequately  carried  out  in  a  special  hospital.  After  two  months' 
contact  with  the  dispensary,  she  herself  asked  the  physician  to 
make  the  necessary  arrangements  for  her  admission  to  the  state 
hospital.  After  a  stay  of  over  a  year  in  the  hospital  she  left  it 
and  visited  the  dispensary;  she  still  clung  to  her  old  ideas  and  did 
not  accept  the  physician's  view  of  her  sickness,  but  she  had  no 
resentment  against  him  for  having  sent  her  for  treatment  to  a 
mental  hospital.  Some  months  later,  unable  to  establish  herself 
in  the  community,  she  returned  voluntarily  to  the  state  hospital. 

The  detailed  treatment  of  the  individual  case,  so  far  as  the 
analysis  of  the  symptoms  and  the  readjustment  of  the  patient's 
attitude  are  concerned,  belongs  more  to  a  technical  medical  dis- 
cussion than  to  the  present  review,  which  aims  more  at  a  discus- 
sion of  the  objective  methods  involving  social  co-operation.  It 
may  be  helpful  to  mention  briefly  those  social  organizations  with 
which  the  psychiatric  dispensary  must  keep  in  touch,  through  its 
social  service  department.  To  a  large  extent  they  supply  the 
machinery  for  the  readjustment  of  the  patient,  and  the  problem  of 
the  psychiatric  social  service  worker  is  largely  to  co-ordinate 
their  individual  services.  Contact  with  these  organizations  to  be 
efficient  must  be  personal  and  intimate,  not  formal  and  perfunc- 
tory. 

The  dispensary  must  be  in  close  touch  with  the  school  system 
and  co-operate  with  principals  and  teachers,  so  that  their  problems 
are  freely  referred  to  the  dispensary,  and  its  advice  actually  carried 


MENTAL  HEALTH  OF  THE   COMMUNITY  11 

into  practice.  Similar  relations  should  exist  with  the  juvenile 
court,  with  reform  and  parental  schools,  and  with  all  official 
charity  organizations,  for  no  organization  can  deal  adequately 
with  the  problems  of  dependency  which  does  not  realize  the  r6le 
played  by  mental  defect  or  disorder.  These  organizations  can 
not  only  bring  their  problems  to  the  dispensary,  but  make  a 
valuable  social  apparatus  available  for  the  readjustment  of  the 
psychiatric  patient. 

Such  readjustment  is  often  facilitated  when  the  psychiatric 
worker  is  in  touch  with  the  large  employers  of  labor  and  with 
employment  bureaus,  such  as  the  new  Federal  Employment 
Bureau;  the  economic  readjustment  is  often  an  essential  part  of 
the  total  task. 

For  the  development  of  those  human  interests  which  are  such 
important  balancing  factors  in  life,  one  must  be  in  touch  with  the 
local  opportunities  for  promoting  self -culture,  with  organizations 
such  as  the  night  schools,  the  Jewish  Educational  Alliance,  the 
Y.  M.  C.  A.  and  the  Y.  W.  C.  A.  The  patient  may  also  be  grate- 
ful for  some  help  in  utilizing  the  other  cultural  opportunities  of 
the  community,  the  museums,  libraries,  picture-galleries  and 
concerts.  Simple  recreative  opportunities  are  sometimes  to  be 
found  in  well-run  municipal  dance-halls,  while  the  humble 
"movies"  may  be  recommended  as  an  invaluable  diversion  in  a 
community  where  the  only  alternative  is  the  saloon. 

For  physical  culture,  the  development  of  the  corpus  sanum 
as  a  fit  temple  for  the  ideal  mens  sana,  one  must  be  able  to  utilize 
the  gymnasia  associated  with  the  above  organizations,  with  several 
churches,  with  the  Public  Athletic  League,  while  in  summer  healthy 
exercise  and  recreative  diversion  are  combined  in  summer  camps, 
perhaps  under  the  auspices  of  the  Boy  Scouts  or  the  Camp  Fire 
Girls. 

Where  the  patient  has  not  cut  himself  adrift  from  his  organic 
church  affiliations,  it  is  important  that  this  most  potent  influence 
in  human  life  should  play  its  r6le  in  the  readjustment  or  hygienic 
resurrection  of  the  individual.  This  is  to  be  done  not  by  referring 
the  patient  to  some  hybrid  organization,  a  blend  of  church  and 
medicine,  but  by  restoring  the  patient  to  the  fellowship  of  that 
church  of  which  he  was  an  organic  member;  with  his  fellow- 
members  he  is  entitled  to  get  from  his  spiritual  guide  some  prac- 
tical help  in  harmonizing  his  highest  needs  with  the  other  insistent 
demands  of  human  nature.  Co-operation  of  this  type  will  be 


12  MENTAL  HYGIENE 

more  generally  available  when  those  preparing  to  be  the  spiritual 
leaders  in  the  community  are  offered,  during  their  training,  a 
psychology  that  deals  with  the  actual  conflicts  of  the  home  and 
the  market,  and  not  a  sterilized  laboratory  psychology. 

Here  may  well  end  our  brief  sketch  of  the  organic  connections 
of  the  psychiatric  dispensary  with  the  life  of  the  community,  and 
of  the  task  of  those  who  help  us  in  building  up  again  the  struc- 
ture of  human  lives  which  have  been  badly  shaken. 

"And  difficult  as  it  may  be  to  transform  the  instincts  that  dwell 
in  the  soul,  it  is  well  that  those  who  build  not  should  be  made 
aware  of  the  joy  that  the  others  experience  as  they  incessantly 
pile  stone  upon  stone.  Their  thoughts  and  attachments,  and 
love;  their  convictions,  deceptions  and  even  their  doubts — all 
stand  in  good  service;  and  when  the  passing  storm  has  demolished 
their  mansion,  they  build  once  again  with  the  ruins,  a  little  dis- 
tance away,  something  less  stately  perhaps,  but  better  adapted 
to  all  the  requirements  of  life." 

SUMMARY 

Indigestion  and  headache  may  be  mental  disorders  just  as  truly 
as  are  morbid  phantasies  and  distorted  attitudes;  it  depends  on 
their  origin. 

The  mental  out-patient  department  or  psychiatric  dispensary 
of  a  hospital  deals  with  symptoms  of  mental  origin,  whether  the 
symptoms  are  called  physical  or  mental. 

The  psychiatric  dispensary  will  be  of  the  greatest  value  to 
the  community  when  physicians  and  social  workers  who  come  into 
contact  with  cases  of  mental  disorder  or  defect  know  the  type  of 
work  done  there. 

The  teacher  who  promptly  secures  a  psychiatric  opinion  on  her 
subnormal  and  neurotic  pupils,  develops  deeper  insight  into  her 
own  special  educational  task. 

The  basis  of  much  philanthropic  work  can  be  broadened  if  the 
psychiatric  dispensary  is  freely  consulted  by  workers  dealing  with 
the  dependents  on  society,  delinquents,  prisoners,  vagrants,  drug 
addicts,  unmarried  mothers,  etc. 

Many  patients  with  mental  symptoms  have  somatic  disorders 
and  present  no  different  problems  from  those  met  in  the  general 
dispensary.  Other  patients  do  not  react  to  the  ordinary  medical 
treatment  (drugs,  baths,  exercise,  rest,  operation,  etc.)  because  the 
symptoms  are  interwoven  with  the  personal  difficulties  of  the 


MENTAL  HEALTH  OF  THE   COMMUNITY  13 

patient.  The  psychiatric  dispensary,  receiving  these  patients 
from  the  general  dispensary  or  from  outside  physicians,  helps  to 
keep  before  the  medical  profession  the  importance  of  certain 
factors  of  health  too  often  neglected,  namely  those  factors  which 
are  the  special  province  of  mental  hygiene. 

The  treatment  of  a  patient  often  means  his  re-education,  his 
revaluation  of  the  various  factors  in  life,  his  progress  from  an  im- 
mature attitude  to  one  more  mature  and  honest.  Difficulties  in 
the  life-situation  of  the  patient  which  are  open  to  modification 
must  not  be  neglected.  At  the  same  time,  more  hygienic  adapta- 
tion to  the  complex  demands  of  life,  the  formation  of  better 
social  habits,  are  complex  tasks  where  supervision  by  an  intelli- 
gent social  service  worker  is  invaluable. 

The  social  service  worker,  to  be  of  practical  use  to  the  patients, 
must  keep  in  intimate  personal  touch  with  many  aspects  of  the 
community  life,  economic,  educational,  philanthropic,  religious 
and  recreative. 

The  treatment  of  a  patient  frequently  means  the  treatment  of 
his  whole  domestic  and  economic  situation;  the  thorough  per- 
formance of  this  task  is  to  be  considered  preventive  medicine. 


to* 


A     000  494  970     7 


MENTAL  HYGIENE 

QUARTERLY  MAGAZINE  OF 

THE  NATIONAL  COMMITTEE   FOR  MENTAL  HYGIENE,  INC. 

EDITOBIAL  OFFICE:  50  UNION  SQUARE.  NEW  YORK  CITY 


EDITORIAL  BOARD 
THOMAS  W.  SALMON,  M.D. 

Medical  Director,  The  National  Committee  for  Mental  Hygiene 

FRANKWOOD  E.  WILLIAMS,  M.D. 

Associate  Medical  Director,  The  National  Committee  for  Mental  Hygiene 

GEORGE  BLUMER,  M.D.         WALTER  E.  FERNALD,  M.D. 

Dean  of  the  Yale  Medical  School  Superintendent,  Massachusetts  School  for  Feebleminded 

C.  MACFIE  CAMPBELL,  M.D.  AUGUST  HOCH,  M.D. 

Anociate  Professor  of  Psychiatry,  Johns  Hopkins  University      Former  Director,  Psychiatric  Institute,  N.  Y.  State  Hospital 

STEPHEN  P.  DUGGAN,  PH.D.  STEWART  PATON,  M.D. 

Professor  of  Education,  College  of  the  City  of  New  York  Lecturer  in  N  euro-biology,  Princeton  University 

VOL.  II,  No.  1  INDEX  JANUARY,  1918 

The  Management  of  War  Neuroses  and  Allied  Disorders  in  the  Army [Col.]  Sir  John  Collie  1 

Mental  Health  for  Normal  Children William  H.  Burnham  19 

A  Consideration  of  Conduct  Disorders  in  the  Feebleminded L.  Pierce  Clark  23 

Feeblemindedness  and  Industrial  Relations C.  S.  Rossy  84 

The  Practical  Function  of  the  Psychiatric  Clinic John  T.  MacCurdy  53 

The  Family  of  the  Neurosyphilitic Harry  C.  Solomon,  Maida  H.  Solomon  71 

Better  Statistics  of  Mental  Diseases Horatio  M.  Pollock  81 

Special  Article 

A  Study  of  608  Admissions  to  Sing  Sing  Prison Bernard  Glueck  85 

Notes  and  Comments 152 

Book  Reviews 162 

Current  Bibliography Mabel  W.  Brown  168 

Directory  of  Societies  and  Committees  for  Mental  Hygiene 173 

MENTAL  HYGIENE  will  aim  to  bring  dependable  information  to  everyone 
whose  interest  or  whose  work  brings  him  into  contact  with  mental  problems. 
Writers  of  authority  will  present  original  communications  and  reviews  of  impor- 
tant books ;  noteworthy  articles  in  periodicals  out  of  convenient  reach  of  the  general 
public  will  be  republished;  reports  of  surveys,  special  investigations,  and  new 
methods  of  prevention  or  treatment  in  the  broad  field  of  mental  hygiene  and  psy- 
chopathology  will  be  presented  and  discussed  in  as  non-technical  a  way  as  possible. 
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